PDF Clinical Information System (CIS) Inventory*

Clinical Information System (CIS)

Inventory*

*This worksheet was adapted from a 2011 book published by the Healthcare Information and Management Systems Society (HIMSS) entitled "Improving Outcomes with Clinical Decision Support: An Implementer's Guide, Second Edition."

Conduct and document an inventory of your organization's CIS that could play a role in delivering CDS interventions. For each system, note its pertinent CDS capabilities, coding systems and current usage.

The information presented should help you survey the CIS applications in your organization to determine what information technology infrastructure is available to help you achieve your goals and objectives. Think broadly about what applications might be pertinent. Key executives or staff in your IT department can be a good starting point for gathering the information about the breadth and details of pertinent systems. Include in your survey all the different clinical content and knowledge resources that are available in your organization to support clinical care and decision making. This might include content that has been developed locally, such as clinical protocols and guidelines, or content that is licensed from content vendors, such as clinical reference databases or knowledge components integrated into the CIS. While in most cases the information will be in electronic format and delivered via electronic clinical information systems, remember that paper-based CDS interventions (e.g., relevant data summaries, order sets) can be effective and may have a role in your program. Your organization's clinical knowledge resources provide an initial content base for achieving the clinical goals within the CDS program. Some of these assets might be stand-alone reference databases, while others might be tightly integrated into specific clinical systems (for example, drug interaction detection within CPOE). Additional content (developed locally, shared with other institutions, or acquired from CIS or content vendors) may be required to optimally address the CDS program goals. The knowledge asset survey provides a foundation for making this assessment in Chapter 3.

In the first column of this worksheet, list the name and system type for all the CIS components that you have identified in your survey of IS pertinent to your CDS efforts (see discussion in chapter). Consider subdividing the list by IS type. If there are many available systems, you might initially focus on those that appear most relevant and powerful for achieving your priority CDS objectives. Keep in mind that the more comprehensively you outline your infrastructure, the easier it will be to identify potential CDS intervention options that are available in your environment.

In the second column, begin noting which of the CDS intervention types that each system can deliver or facilitate. You might need to refine this section as you get into more intervention development details

Coded data are important in certain CDS interventions. In the third column, document the information types the system handles and any coding schemes used. Again, pay particular

attention to key items, such as laboratory test names, drug names, and patients' clinical problems.

The fourth column is for documenting the system user types and how well the system is penetrated into that user population. The notes column can be used to document other key system features, such as any knowledge bases it contains and its interoperability with other key systems.

CIS Inventory

System Name / Type Ordering See clinical records, next Clinical records and patient management Better Care Inc./Inpatient EMR and CPOE

CDS-related Functionality

? Order sets ? Documentation

templates ? Relevant data

display ? Alerts

Information Types (Coding System)

System Users Notes and Usage

? Diagnosis information (ICD10);

? Order information (CPT); ? Lab results (LOINC); ? Imaging results (homegrown

scheme)

Nurses, doctors, and pharmacists; 50% of physicians are currently using

Uses drug knowledge base from XYZ Corp for drug interaction and allergy alerting

Outpatient Computer Corp.

Given Meds Corp.

Departmental data management Get your labs inc.

? Order sets ? Documentation

templates ? Relevant data

display ? Alerts ? Alerts ? Documentation

templates ? Relevant data

display

? Relevant data display

? Alerts

? Visit diagnosis (ICD-10) ? Problem lists (ICD-10) ? Medication lists (National

Drug Code [NDC]) ? Visit notes (Text)

?

? Date/time for medication administration

? Medications (NDC) ? Dose administered

? Lab results (LOINC) ? Anatomic pathology results

(Text)

Clinical content Know-it-all Reference

? Disease and drug reference ? infobuttons capability

? Disease management info (ICD-9)

? Drug reference info (NDC)

25% of outpatient clinics, mostly primary care

Not yet exchanging data well with inpatient system

100% of nurses at two hospitals

Linked to handheld devices

Doctors, nurses, pharmacists all use it frequently

Doctors, nurses, pharmacists all use it frequently

Linked to handheld devices

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